I'm not sure if this comes as a surprise to readers, but many people with chronic disease don't do a very good job of following their treatment recommendations. Between 15 and 30% of new prescriptions written are never filled, and after 6 months of treatment have passed, more than half of people with a chronic condition have stopped their therapy. In some diseases that percentage is even higher. And it's not just because people don't think their treatment is helpful; a quarter of those who stop long-term treatment for autoimmune diseases, for example, do so because the treatment has been working and it is making them feel better!

If there existed a blockbuster drug that would save the U.S. healthcare system 300 billion dollars a year and improve healthcare outcomes, I think that everybody (including those who "own the risk" ...see more about this odd concept below) would jump at the chance to use it! With many diseases, the costs of care over the long term can be very high. If HIV patients fail to take medication regularly and correctly, they can end up experiencing many expensive hospitalizations. If diabetics do not properly test their glucose levels, use insulin, and follow appropriate diet and exercise regimens, the costs of care can increase dramatically; heart disease, amputations, and kidney failure can (as they say) "complicate the clinical picture" not to mention make life pretty miserable for the patient.

Adherenceto treatment is that blockbuster drug, the magic bullet, the path to better health and financial savings --but achieving it seems to be above everybody's pay grade. It's tempting to think that people would always follow their treatments correctly if only their medicines were not so expensive, or if only those medicines didn't cause unwanted side effects, or if only their health professionals just gave them more information and advice. While these factors (and many more) do matter, no one factor matters a great deal. In other words, no simple set of explanations works for everyone.

For every person with an adherence challenge, there's a unique set of reasons causing it. For example, Patient A might simply not understand the reason for her prescription in the first place. And she might remember incorrectly what her doctor told her. Indeed, 40 to 80 percent of the information that doctors give their patients during the office visit is forgotten or remembered incorrectly by the time the person gets to the waiting room! Perhaps Patient A goes home and tells a family member what she recalls from the visit, and that family member looks up treatments and medications on the internet (where a large proportion of health advice is actually incorrect). The family member might hint at his concerns about the regimen and so the medication remains unused. At the patient's follow-up appointment a few months later, she tries to get through the ten minute medical visit without having to admit that she didn't understand, didn't believe in, and consequently didn't follow the prescription. The physician thinks all is well, or (worse) increases the dosage because the lower dose (which was never taken) appears not to have worked. Patient B might genuinely plan to adhere to treatment. But he doesn't have anyone to help with food shopping and preparation, emotional support for exercise, or reminders to take medication. He might also be moderately depressed and feeling pessimistic and hopeless, withdrawing from others, and having difficulty thinking and planning. Treatment adherence ends up on the back burner most days.

The most effective and least costly way to manage chronic disease involves helping patients adhere to the treatment prescribed for them, and supporting providers to focus on treatment adherence. Those who "own the risk" for patient outcomes would do well to invest in ways to help with adherence. "Owning the risk" seems like an odd concept, but it's a simple one. Although a patient must ultimately deal with the daily consequences of any health challenge, it is the financial risk of care that we are referring to here. If an employer offers health insurance, the rising costs of that insurance must be borne across the "risk pool" of employees, and when health costs go up, so do premiums. There is incentive to control costs and insure optimal care. One ideal situation for the reduction of financial risk is in an Accountable Care Organization (ACO) that maintains a focus on insuring that chronically ill patients receive correct, coordinated care as well as necessary support to maintain their commitment to treatment. More problematic are situations in which chronically ill individuals (often for financial reasons) switch insurance companies and providers year after year, and receive uncoordinated and episodic care. The danger here is that few patients will find a healthcare provider who helps them improve their adherence and manage their chronic diseases successfully over the long term. Healthcare costs keep climbing partly because there is an incentive to "kick the risk down the road"-- to the next health plan, or the next employer.

An example of the disastrous results of kicking the risk down the road is the creation of opioid addiction from the poor management of low back pain, which I wrote about in February 2016. Imagine that a patient with low back pain really needs and (as research shows) would likely benefit greatly from physical therapy, exercise, and some Cognitive Behavior Modification. These approaches require a coordinated effort by health professionals as well as payment coverage by insurance; they are far less expensive and more likely to work than surgery. With support to adhere to back exercises and behavior change (such as losing weight and keeping it off, and lifelong attention to body mechanics while moving, lifting, and carrying things), patients with low back pain have a very good chance of effectively managing their pain throughout their lives. Additional complementary medicine treatments like massage and acupuncture are also likely to be helpful in the earlier stages to help manage pain and get the patient moving. But limits on physical therapy, acupuncture, and psychotherapy coverage in most health plans, as well as a general absence of focus on helping patients adhere to behavioral change, can push the patient's treatment toward the quickest and least expensive short-term solution --a prescription for opioid painkillers.

Medical care is going to get more expensive. By 2020, it is expected that 157 million people in the U.S. will be living with at least one chronic disease and 81 million will have multiple chronic illnesses like diabetes, heart disease, hypertension, stroke, back pain, depression, and cancer to name a few. The best and the most effective treatments for these conditions will only work if people adhere to them, and in order to achieve optimal outcomes and manage costs, all patients, providers, and health systems need to be engaged in promoting adherence to treatment.

For more information on adherence, please check out the tab above entitled "PDFs of Published Work" where you will find a number of my written articles about treatment adherence.

Also, the link below will take you to my recent presentation for health professionals offered by QuantiaMD:Improving Your Patients’ Adherence to Treatment RecommendationsIn order to view/listen to the entire slide presentation-- and many more --you will be asked to register. The service is free and filled with great information about many topics in healthcare.